CLINICAL DOCUMENTATION (Domain 1)
Use separate codes for hypertension and acute renal failure
A 64-year-old female was discharged with the final diagnosis of acute renal failure and hypertension. What coding rule applies?
Major depression
A patient is admitted to a psychiatric unit of an acute-care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities, which is a change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions. What potential diagnosis most closely fits the patients overall symptoms?
Abdominal adhesions with obstruction, lysis of adhesions
A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it was determined that the patient had an intestinal obstruction of the left colon due to adhesions from a prior abdominal surgery. The patient underwent a laparotomy with lysis of adhesionns. What conditions and procedures should be coded?
(Review of the operative report to determine what procedure code to use. Determine the site or sites of endometriosis so codes with the highest specificity may be assigned. Assign endometriosis as the principal diagnosis. Assign infertility as a secondary condition.) Review, Site, Principal, Secondary
A patient is diagnosed with infertility due to endometriosis and undergoes an outpatient laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately, what steps must the coder take?
It is incorrect because the physician did not document the blood loss anemia in the progress notes
A policy states that inpatients who undergo open reduction and internal fixation of a fractured femur should be routinely coded with blood loss anemia when there is intraoperative blood loss of 500 cc or more documented in the operative report and the patient has low hemoglobin. Is this correct or incorrect, why?
Be completed for each patient no more than 30 days before or 24 after admission or registration, but prior to surgery.
According to medicare requirements, a history and physical must:
prove authorship of documents
Authentication of health record entries means to:
care rendered to the patient and the patient's response
In order to establish the adequacy of documentation in the medical record, the following must be reflected:
continuity of care
Proper discharge planning for inpatients being transferred to another healthcare delivery system must include a complete summary of the patient's history, current status,, and future needs to ensure appropriate:
Medical staff bylaws
The requirements for documentation and record completion (documents such as history and physicals, discharge summaries, and consultations) as well as penalties for non-adherence must be specified in:
Patient is found to have dysphagia with aspiration
a patient has a principal diagnosis of pneumonia (J18.9) (MS-DRG 195). Which of the following may legitimately change the coding of pneumonia in accordance with the UHDDS and relevant clinical documentation?
Urinary tract infection, Escherichia coli
a patient is admitted and diagnosed with fever and urinary burning. The discharge diagnosis is Escherichia coli, urinary tract infection. What represents the correct diagnosis and appropriate sequence of those conditions?
Query the physician
a patient was admitted with heart failure within one week of aheart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant, What action(s) should the coding staff take?
Myocardial infaction
the patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes, The EKG shows nonspecific ST changes. What type of diagnosis might this indicate?